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- Department of Obstetrics & Gynecology, Al-Khor Hospital, Hamad Medical Corporation, Qatar [2]
- Department of Anaesthesiology, SICU, Pain Management and Perioperative Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar [1]
- Department of Anesthesiology, SICU, Pain Management and Perioperative Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar [1]
- Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar [1]
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- Weill Cornell Medicine, Cornell University, Doha, Qatar Email: [email protected] [1]
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Puerperal sepsis and multiple organ dysfunctions caused by group A streptococcus
Background: Child fever or puerperal sepsis is a significant cause of maternal morbidity and mortality. It is a preventable maternal postpartum complication.1 Group A streptococcus (GAS) infection remains a significant cause for postpartum sepsis as it causes septic shock and multiple organ dysfunction (MODS). There has been a resurgence of severe puerperal GAS infections over the past two decades although rare it must be recognized early and treated aggressively. GAS is a common bacteria causing necrotizing fasciitis (NEF) in our region2 but it caused NEF in only one postpartum patient which is a rarity.345 We report a case of puerperal GAS infection-causing NEF where the patient underwent multiple surgical debridements complicated with septic shock and MODS and had a fairly positive outcome.
Case presentation: A 26-year old female presented to the emergency department 5 days postpartum with fever tachycardia tachypnea borderline blood pressure vaginal discharge and severe pain in the right leg. Her physical examination revealed reddish discoloration of the right lower leg which was edematous warm and extremely tender. The episiotomy wound looked dirty and infected. She had leukocytosis (29.2 × 103/μL) thrombocytopenia (44 × 103/μL) C-Reactive protein was elevated (322 mg/L) and serum lactic acid was 3.8 mmol/L. Her hepatic and renal parameter were elevated. She had a deranged coagulation profile. Post-partum sepsis was suspected and blood cultures were done. She was started on Tazocin® (Tazobactum+piperacillin) supplemented with oxygen and resuscitated with intravenous fluids.
She was immediately taken for emergency surgical intervention right leg debridement and fasciotomy with exploration of the episiotomy wound was performed. Surgical findings were dirty colored fluid collection and loss of facial resistance which corroborated with NEF. Necrotic tissues were sent for histopathology and cultures and clindamycin was started. Intraoperatively the patient became unstable requiring double vasopressor (noradrenaline and vasopressin) to maintain the hemodynamics. Postoperatively the patient was kept sedated and ventilated in the intensive care unit (ICU). She required four debridements in the next two days despite which her right leg was not improving. Magnetic resonance imaging showed necrotizing fasciitis of the right thigh and leg. Tissue biopsy confirmed the diagnosis. Her blood and tissues showed growth of group A streptococcus. With family agreement she underwent above right knee amputation lateral and medial thigh compartment fasciotomy and debridement on day five. She was oozing from the fasciotomy wounds and needed resuscitation with blood and blood products. She started to show signs of improvement and was weaned off from vasopressors and ventilator. Hepatic and renal functions improved (Figure 1 and Table 1). She was extubated on day 12 awake hemodynamically stable tolerated oral feeding and was transferred to the surgical ward on day 19. She was discharged home on day 24 and was followed in surgical outpatient clinics.
Conclusion: Despite developments in infection control and strict aseptic precautions GAS puerperal sepsis remains a potentially life-threatening infection especially when they present with rare conditions like NEF in the postpartum period. Early diagnosis aggressive surgical management and supportive medical care are important for a positive outcome.
Scoline apnoea and pregnancy: SICU experiences
Background: Suxamethonium chloride (scoline) is a short acting depolarizing muscle relaxant; it was discovered early in the nineteenth century but not used in clinical practice until 1951.1 Scoline became a popular muscle relaxant due to its rapid onset of action quick metabolism and hence shorter duration of action. It is metabolized by cholinesterase. Scoline apnoea was described within a few years of clinical use of Suxamethonium due to inherited or acquired deficiency of the cholinesterase enzyme resulting in prolonged muscle relaxation.2 Now scoline is used in prehospital and emergency intubating conditions in pregnancy fetal distress or cord prolapse due to obvious advantages in these circumstances.345 The aim of our study was to investigate the trends and incidence of scoline apnoea in pregnant patients. Patients and methods: All patients admitted with scoline apnoea during pregnancy in the surgical intensive care unit of a tertiary healthcare facility were included retrospectively in our study. Patients demographic data duration of apnoea and intubation intensive care unit stay and trends of scoline apnoea were recorded. Results: A total of 32 pregnant patients post-lower segment caesarean section were admitted to the surgical intensive care unit during the study period. The indications for general anaesthesia in the majority of patients were obstetrical emergencies (n = 23 71.87%) refused regional anaesthesia (n = 7 21.87%) and required general anaesthesia after the regional anaesthesia (n = 2 6.25%) patients. Twenty-nine (90.62%) patients received premedication with metoclopramide and sodium citrate (Table 1a). Thirty (93.75%) patients received reversal combination of neostigmine and atropine. Four (12.50%) patients received fresh frozen plasma (Table 1a). The mean age of the patients was 31.7 ± 6.4 years old (minimal age was 25 years) all patients belonged to ASA class 1 and the mean duration of apnoea time was 4 ± 2.5 hours. The duration of intubation was 6 ± 4.5 hours and the length of surgical intensive care stay was 1.2 ± 0.7 days (Table 1b).
As shown in Figure 1a the majority of patients were found to belong to the age group of 31 to 35 years (n = 12 37.5%) followed by 9 (28.12%) patients in the age group of 26 to 30 years. It was also found that the Qatari locals and Egyptians formed the majority nationality (n = 12 37.5% and n = 7 21.87%) of patients (Figure 1b). The overall Arab patient population had a higher incidence of scoline apnoea compared to the Asian group of patients.
All patients were found to have cholinesterase levels below 3500 units/litre (normal range varies from 5400 to 13200 units/litres) which is less than 70% of the normal value (Figure 2a).
There was a decreasing trend of scoline apnoea patients in recent years. From 2013 to 2016 there were no patients admitted to SICU with scoline apnoea and in 2017 only one patient with scoline apnoea was admitted (Figure 2b). Conclusion: Scoline apnoea incidence and trend in our parturient population is decreasing. The majority of our patients received premedication and reversal medication which decreases the cholinesterase levels. The decreasing trend may be attributable to increased regional anaesthesia practice and frequent use of rocuronium.